Commercial General Liability, in case of bodily injury or

Please forward application to:
Lussier Dale Parizeau
Suite 700, 3400 de Maisonneuve Blvd. West
Montreal, Quebec H3Z 0A5
Telephone 514-282-1112
Facsimile 514-868-6427
Toll Free 800-361-8715
Fax Free
877-807-8887
www.lussierdaleparizeau.ca
Application
Professional Liability Insurance and
Commercial General Liability Insurance for
the Members of the
Order of Professional Technologists of Quebec
Please answer all of the questions. If any questions do not apply to your situation, indicate this by writing “N/A”.
Please attach any pertinent document for the review of your file.
THE APPLICANT
1.
Name of the technologist:
2.
Address:
Telephone (residence):
Telephone (business):
Facsimile:
Email:
3.
Website Address (if applicable):
4.
Corporate Name of your private practice business:
5.
This business is a:
6.
Date operations began:
7.
Your Current Situation:
8.
(a) Have you already been an owner, partner or shareholder of a company in the past?
Corporation
General Partnership
Undeclared Partnership
Owner
Partner/Shareholder
Employee
YES
NO
If yes, please indicate the name of the company:
(b) Date that company stopped doing business:
9.
Please describe your professional practice:
10. Is the Applicant controlled by, associated with, operated by, managed by or a member of another firm?
YES
NO
If yes, please explain:
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11. Information on all individuals (including yourself) working for the Applicant. (Attach an additional page if
necessary.)
Family Name and Given Name
Duties/Title
PT Member Number
Date of Employment
(month/day/year)
12. Please describe your five (5) most significant projects carried out during the last ten (10) years. Include a
brochure if one is available. Attach an additional page if necessary.
13. Please indicate your income for each of the following categories:
Category
Technical consulting
Plans and estimates
Appraisals, analyses
Training, instruction
Pre-purchase building inspections
Number of inspections the last 12 months _________
Number of inspections the next 12 months _________
Project management
Site surveillance
Distribution, sales
Manufacture, assembly
Contractor, installation
Design-build
Q-2,R.22/Q-2,R.8 Mandatory training with the Order
If none, please contact the Order
Other (please describe: __________________________________)
Total
Construction value
Work assigned to subcontractors
Income earned outside of Canada (specify country: ____________)
Actual Income
(last 12 months)
$
$
$
$
$
Projected Income
(next 12 months)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
14. Please indicate your working technology number (refer to page 5):
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COMMERCIAL GENERAL LIABILITY
15. List all buildings, owned or rented by the Applicant, that are the subject of this application:
Address
Rent or Own
Area (m2)
Age
Construction
(frame, brick, etc.)
No. of Stories
INSURANCE COVERAGE
16. Please provide details about your previous professional liability insurance or commercial general liability
insurance policies:
Insurer
Policy No.
Policy Period
Expiring Premium
Limit
Deductible
$
$
$
$
$
$
$
$
$
17. To the Applicant’s knowledge, has an insurance company ever refused to insure or renew their professional
liability or commercial general liability insurance or that of their partners, current officers or any business
NO
predecessors, or past partners or officers?
YES
If yes, please explain:
KNOWLEDGE OF PRIOR CLAIMS
18. To the Applicant’s knowledge, has any claim been filed against them, their business predecessors, partners, or
NO
current or past officers?
YES
If yes, please provide details:
19. Is the Applicant aware of any act, error, fault, omission or circumstance that could result in a claim against them,
NO
their business predecessors, or any past or current partner or officer?
YES
If yes, please provide details:
WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURERS, IT IS AGREED THAT,
IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR
ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE
PROPOSED INSURANCE.
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LIMITS REQUESTED
Class of Insurance
Deductible
Individual Limits Required
The base limit per claim is $250,000.
Additional limits per claim are also
available.
$2,500 per claim and
$5,000 for home inspectors
Professional Liability
$500,000
$1,000,000
Other: $________________________
Commercial General
Liability
$2,500 per occurrence for property
damage and bodily injury, and $5,000
for home inspectors
The base limit per occurrence is $2,000,000.
Additional limits per occurrence are also
available.
Required limit: $____________________
APPLICANT’S CONSENT TO THE TRANSMISSION OF THE
INFORMATION CONTAINED IN THE APPLICATION FORM
I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to
be transmitted to ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept
confidential.
Moreover, I authorize ENCON Group Inc., its insurers or service providers to:
• conduct verification, using outside sources, of the information contained in the Application form, in attached
documentation and in subsequently provided documentation;
• in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar
offices for the purposes of investigating, defending, negotiating or settling any claims, as required.
For more information on ENCON’s privacy policy, please contact [email protected].
DECLARATIONS AND SIGNATURE
The undersigned Applicant for this insurance declares that, to the best of their knowledge and belief, the statements set
forth herein are true and correct, and that reasonable efforts have been made to obtain sufficient information to facilitate
the proper and accurate completion of this Application form. The undersigned agrees that, if any significant change in
the condition of the Applicant is discovered between the date of this Application form and the effective date of the
policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported
immediately in writing to the Insurance Manager.
Although the signing of this Application form does not bind the Applicant to purchase the insurance, the undersigned
Applicant further agrees that this form and the information furnished pursuant hereto shall be the basis of the contract
should a policy be issued and this form will become part of the policy.
Name of Applicant (please print)
Signature of Applicant
OTPQ33E-SRD-15
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Date
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© 2016 ENCON Group Inc.
Technologies admissibles à l’Ordre des technologues professionnels du Québec
Administration, commerce et informatique
420.AA Techniques de l’informatique – informatique de gestion
420.AB Techniques de l’informatique – informatique industrielle
420.AC Techniques de l’informatique – gestion de réseaux
informatiques
153.BD
Agriculture et pêches
Transformation des produits de la mer
Techniques d’aquaculture
Techniques de santé animale
Technologie du génie agromécanique
Gestion et exploitation d’entreprise agricole – Productions
animales
Gestion et exploitation d’entreprise agricole – Productions
végétales
Technologie des productions animales
Technologie de la production horticole et de l’environnement
Cultures légumières, fruitières et industrielles
Cultures de plante ornementales
Cultures horticoles, légumières, fruitières et
ornementales en serre et en champs
Environnement
154.A0
Alimentation et tourisme
Technologie de la transformation des aliments
570.C0
Arts
Techniques de design industriel
231.B0
231.A0
145.A0
153.D0
152.AA
152.AB
153.A0
153.B0
153.BA
153.BB
153.BC
248.C0
280.C0
Environnement et aménagement du territoire
145.B0 Techniques d’aménagement cynégétique et halieutique
145.C0 Techniques de bioécologie
147.AA Techniques du milieu naturel – Aménagement de la ressource
forestière
147.AB Techniques du milieu naturel – Aménagement de la faune
147.AD Techniques du milieu naturel – Protection de l’environnement
222.A0 Techniques d’aménagement et d’urbanisme
Fabrication mécanique
235.B0 Technologie du génie industriel
235.C0 Technologie de la production pharmaceutique
241.12 Techniques de transformation des matières plastiques
241.A0 Techniques de génie mécanique
241.C0 Techniques de transformation de matériaux composites
248.A0 Technologie d’architecture navale
280.B0 Techniques de construction aéronautique
Foresterie et papier
190.A0 Technologie de la transformation des produits forestiers
190.B0 Technologie forestière
232.A0 Technologie des pâtes et papiers
241.D0
Bâtiment et travaux publics
Technologie de l’architecture
Technologie du génie civil
Technologie de la mécanique du bâtiment
Technologie de l’estimation et de l’évaluation en
bâtiment – Estimation en construction
221.DB Technologie de l’estimation et de l’évaluation en
bâtiment – Évaluation immobilière
230.AA Technologie de la géomatique – Cartographie
230.AB Technologie de la géomatique – Géodésie
221.A0
221.B0
221.C0
221.DA
Chimie et biologie
Techniques de génie chimique
Techniques de laboratoire – Biotechnologies
Techniques de laboratoire – Chimie analytique
Techniques de procédés chimiques
Assainissement de l’eau
Environnement, hygiène et sécurité au travail
243.A0
243.BA
243.BB
243.BC
243.C0
244.A0
280.D0
Électrotechnique
Technologie des systèmes ordinés
Technologie de l’électronique – Télécommunications
Technologie de l’électronique – Ordinateurs et réseaux
Technologie de l’électronique – Audiovisuel
Technologie de l’électronique industrielle
Technologie physique
Techniques d’avionique
Mécanique d’entretien
Technologie de la maintenance industrielle
Mines et travaux de chantier
271.AA Technologie minérale – Géologie
271.AB Technologie minérale – Exploitation
271.AC Technologie minérale – Minéralurgie
Bois et matériaux connexes
233.BA Techniques du meuble et d’ébénisterie – Production sérielle
233.BB Techniques du meuble et d’ébénisterie – Menuiserie
architecturale
210.02
210.AA
210.AB
210.B0
260.A0
260.B0
Entretien d’équipement motorisé
Techniques de génie mécanique de marine
Techniques de maintenance d’aéronefs
Métallurgie
270.AA Technologie du génie métallurgique – Procédés de
transformation
270.AB Technologie du génie métallurgique – Fabrication
mécanosoudée
270.AC Technologie du génie métallurgique – Contrôle et matériaux
Transport
248.B0 Navigation
144.B0
Santé
Techniques d’orthèses et prothèses orthopédiques
Veuillez prendre note que les anciens programmes restent toujours admissibles. Veuillez communiquer avec le service
d’admission pour savoir si d’autres programmes ont été ajoutés.
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